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Clinical
Investigation
Validation of modified Mallampati test with addition
of thyromental distance and sternomental distance
to predict difficult endotracheal intubation in adults

Address for correspondence:
Dr.Rajiv Khandekar,
Department of Research, King
Khalid Eye Specialist Hospital,
POB7191, Riyadh11462,
Saudi Arabia.
Email:rajiv.khandekar@gmail.
com
Access this article online
Website: www.ijaweb.org
DOI: 10.4103/0019-5049.130821
Quick response code
Bhavdip Patel, Rajiv Khandekar, Rashesh Diwan1, Ashok Shah1
Department of Anesthesia, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia, 1Department of
Anesthesia, SAL Hospital, Ahmedabad, Gujarat, India
ABSTRACT
Background and Aims: Intubation is often a challenge for anaesthesiologists. Many parameters
assist to predict difficult intubation. The present study was undertaken to assess the validity of
different parameters in predicting difficult intubation for general anaesthesia (GA) in adults and
effect of combining the parameters on the validity. Methods: The anaesthesiologist assessed
oropharynx of 135 adult patients. Modified Mallampati test (MMT) was used and the thyromental
distance (TMD) and sternomental distances (SMD) for each of the patients were also measured.
The Cormack and Lehane laryngoscopic grading was assessed following laryngoscopy. The
validity parameters such as sensitivity, specificity, false positive and negatives values, positive
and negative predictive values were calculated. The effect of combining different measurements
on the validity was also studied. Univariate analysis was performed using the parametric method.
Results: The study group comprised of 135patients. The sensitivity and specificity of MMT were
28.6% and 93%, respectively. The TMD (<6.5 CM) had sensitivity and specificity of 100% and
75.8%, respectively. The SMD (<12.5 CM) had sensitivity and specificity of 91% and 92.7%,
respectively. Combination of MMT grading and TMD and SMD measurements increased the
validity (sensitivity of 100% and specificity of 92.7%). Conclusion: MMT had high specificity.
The validity of combination of MMT, SMD and TMD as compared to MMT alone was very high
in predicting difficult intubation in adult patients. All parameters should be used in assessing an
adult patient for surgery under GA.

Key words: Anaesthesia, endotracheal intubation, modified Mallampatti test, validity

INTRODUCTION incisor-gap aid in assessing a difficult endotracheal

Difficult or failed endotracheal intubations are one of
the leading causes of anaesthesiarelated morbidity
and mortality. The incidence of difficult endotracheal
intubation is 3.2%[1] and includes failed and difficult
intubation, difficult laryngoscopy or difficult mask
ventilation. This risk can be reduced if difficult airway
is evaluated preoperatively.[2] Modified Mallampati
grading (MMT) is a widely used preoperative
evaluation.Other parameters of preoperative
airway assessment including, thyromental distance,
sternomental distance, cervical mobility and Inter-
intubation. The literature has shown uses of different
preoperative measurement parameters in predicting
difficult intubation. However, limited information is
available on effect of combining these parameters in
enhancing the validity parameters.
We undertook a study to compare MMT grading before
surgery to the Cormack Lehanes grading(CLG) of
difficulty in intubation during anaesthesia. We also
evaluated the role of adding other measurements like
thyro mental distance(TMD) and manubrium sterni to
mentum distance(SMD) in enhancing the validity of

How to cite this article: Patel B, Khandekar R, Diwan R, Shah A. Validation of modified Mallampati test with addition of thyromental distance
and sternomental distance to predict difficult endotracheal intubation in adults. Indian J Anaesth 2014;58:171-5.

Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014 171

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Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation
MMT in predicting difficult intubation(based on CLG)
in patients aged 15years and older.
METHODS
The hospital research committee granted approval for
this study. The study was conducted in 135patients
in a multispecialty hospital between November
and December 2010, aged 15 to 80years requiring
general anaesthesia with endotracheal intubation. In
our hospital, children aged 15years and older were
grouped as adults. Hence for logistic reasons, we
included patients aged 15years and above as adults.
Informed written consent was obtained from all
patients. Patients with swelling, scars, contractures
in front of the neck and those with pathological
conditions making intubation a difficult task were
excluded from the study. Data were collected on age,
gender, weight, the type of surgical procedure and
anaesthesia physical status(American Association of
Anesthesiologists(ASA)).
The anaesthesiologist and patients sat at eye level
and thepatient opened his/her mouth as wide as
possible with the tongue protruding. Depending on
the visualization of the oropharyngeal structures, the
patients were graded according to the MMT.[3] Grading
the oropharynx was based on protruding maxillary
teeth(overbite). With the patient in the sitting position
with maximal extension of the head, the neck was
palpated for thyroid notch. The distance between
the thyroid notch and symphysis menti(TMD) was
measured in centimetres with a measuring tape.
With the patient in the sitting position and maximal
extension of the head and the mouth closed, the straight
distance between the upper border of the manubrium
sterni and the bony point of mentum(SMD) was
measured.[4] If TMD was less than 6.5cm, it was
considered as predictor for difficult intubation. If SMD
was less than 12.5cm, we considered it a predictor of
a difficult intubation.
Of the 5,000patients per month that undergo
surgery in our institution, we assumed that 60%
could correctly predict a difficult intubation through
preoperative assessment.[5] For 95% confidence
intervals and 10% precision with clustering effect of
1.5 due to different operation theatres(as the study
sites), we required 136patients in this validity
study. To calculate the sample size, we used Open
Source Epidemiologic Statistics for Public Health,
Version2.3.1.(Open Epi 2.3.1Sweden, Denmark).
172
An investigator performed a standard preoperative
assessment and recorded the findings using a pretested
data collection form. Another investigator who was
not involved in preoperative assessment performed
laryngoscopy without knowing the MMT outcomes
of the patient. He documented the level of difficulty
by grading the patient just prior to intubation and
the actual difficulty during intubation using CLG.
Astatistician who was involved in analyzing the data
was blinded to both the preoperative and intraoperative
results.
Patients remained on an empty stomach for eight
hours and glycopyrrolate 4g/kg and midazolam
20 g/kg was given intravenously 15minutes before
surgery. For general anaesthesia, patients were
given oxygen for 3 to 5minutes. Subsequently,
intravenous injection of fentanyl sodium(2ug/kg)
was administered, followed by a slow injection of
propofol(2mg/kg). After confirming that the patient
could be ventilated by mask(100% oxygen given
for 23minutes), 1.5mg/kg bolus of intravenous
succinylcholine was administered. Neuromuscular
relaxation was monitored and on confirmation,
intubation was attempted. Before laryngoscopy, the
head was extended on a 10cm pack and neck was
flexed to achieve the modified Jackson position. The
laryngoscope was introduced and larynx visualized.
The degree of visualization of larynx was classified
according to the Cormack and Lehane laryngoscopic
grading.[2]
A senior anaesthesiologist with at least two years of
experience performed intubation. If on two or more
attempts, inadequate glottis was visible or not visible
at all, it was considered a difficult intubation. Different
size of laryngoscope blades, McCoy blades, stylet,
bougie, various size of mask, small size of endotracheal
tubes, LMA, Combitube and Cricothyrotomy kit
were part of difficult airway cart. Failed intubation
was defined as inability to insert a tracheal tube
from the oropharynx into the trachea. Details of the
maneuvers during intubation were documented such
as application of external pressure over the larynx, use
of an extralarge blade of laryngoscope or stylet.
To assess the validity of MMT and TMD and
SMD score, we calculated sensitivity, specificity,
false positive, false negative, positive predictive
and negative predictive values. The difficulty in
endotracheal intubation for anaesthesia was the gold
standard for assessing validity. As MPG is a categorical
Indian Journal of Anaesthesia | Vol. 58 | Issue 2 | Mar-Apr 2014
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Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation

variable, we used a 22 table to assess the validity
parameters. The TMD and SMD measurements were
continuous variables. Hence, the Receiver Operating
Characteristic(ROC) curves were plotted to associate
the sensitivity and the specificity. We also used the
standards of TMD <6.5 cm and SMD <12.5 cm to
define an abnormal length of the oropharynx that
could negatively affect intubation. By clubbing these
parameters to the MMT, we assessed the changes in
the validity parameters. The Statistical Package for
Social studies(SPSS version12; IBM Corp., NewYork,
NY, USA) was used for univariate analysis with the
parametric method.
RESULTS
One hundred and thirty five patients(71males and
64females) participated in our study. The mean age
of the participants was 29.71.4years. The mean
weight of the participants was 54.911.1kg. Only
two patients were graded ASA I anaesthesia risk and
the remaining 133cases were ASA II. Laparoscopic
surgeries were planned for 61patients. Other surgeries
included orthopaedic(13patients), ear nose and
throat(ENT)(7patients), urological(12patients) and
general surgeries(42patients).
The incidence of difficult intubation was 8.1%(95%
CI: 3.512.7)]. The mean age of patients classified as
difficult intubation was 40.3years[15.0years standard
deviation(SD)]. The mean age of patients not classified
as difficult intubation was 30.7years(10.7years
SD). The age difference in two groups was not
statistically significant[Mean difference=9.6years;
95% CI:0.619.8; P>0.05].
The mean weight of patients classified under difficult
intubation was 60.3kg(13.1kg SD). The mean weight
of patients not classified as difficult intubation was
54.4kg(10.8kg SD). The weight difference between
groups was not statistically significant[Mean
difference=5.86kg; 95% CI:1.012.9; P>0.05].
in 41 cases. Eleven of these cases were difficult
intubation. All 94 cases in which the TMD
was6.5cm, the intubation was performed without
any difficulty. Thus the sensitivity and specificity of
TMD measurement was 100% and 75.8%, respectively.
The SMD was<12.5cm in 19cases. Ten of these
cases were a difficult intubation. Of these cases
with SMD12.5cm, in only 1 out of 116cases the
intubation was difficult. Thus the sensitivity and
specificity of SMD measurement was 91% and 92.7%,
respectively.
By combining the parameters of TMD and SMD,
we could increase the sensitivity and specificity
parameters of predicting difficult intubation to 100%
and 92.7%, respectively [Table 2].
By combining MMT and(TMD+SMD) parameters,
the sensitivity and specificity of predicting a difficult
intubation increased to 100% and 93%, respectively.
DISCUSSION
By combining parameters thyromental and
steromental distance measurement to the modified
Mallampati Test(MMT) outcomes, the sensitivity to
predict difficult intubation increased from 27% to
100% and the specificity remained 93%. In view of
high predictive values of the combined test, our study
results could be applied to adult population with ASA
II and II undergoing surgery under general anaesthesia.
Table1: Validity of modified Mallampati test method of
predicting difficulty in endotracheal intubation
Grade Difficulty in Total
endotracheal intubation
Difficult Not difficult
Modified III and IV 2 9 11
Mallampati test I and II 5 119 124
7 128 135
Sensitivity=2/7100=28.6, Specificity=119/128100=93.0, False
positive=5/7100=71.4, False negative=9/128100=7.0, Positive predictive
value=2/11100=18.2, Negative predictive value=119/124100=96.0

The validity of MMT in predicting a difficult Table2: Validity of combining all parameters in
intubation was reviewed[Table1]. The sensitivity of predictingdifficult endotracheal intubation
Grade Difficulty in Total
this assessment procedure was 27%. The sensitivity endotracheal intubation
and specificity values of the TMD and SMD parameters Difficult Not difficult
to predict difficult intubation were studied with ROC All predictors II and III 7 4 11
curve. Both TMD and SMD parameters were highly together I 1 123 124
MMT+TMD+SMD 8 127 135
sensitive[Figures1 and 2].
Sensitivity=7/8100=87.5%, Specificity=123/127100=96.9%, False
positive=1/8100=12.5, False negative=4/127100=3.1%, Positive predictive
The TMD of <6.5 cm predicted a difficult intubation value=7/11100=63.6%, Negative predictive value=123/124100=99.2%

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Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation

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Figure1: Validity of ThyroMental Distance in predicting difficulty Figure2: Validity of Sterno Mental Distancein predicting difficulty
in endotracheal intubation. Sensitivity=90% and specificity=90% in endotracheal intubation. Sensitivity=80% and specificity=90%

The incidence of a difficult laryngoscopy or intubation
varies from 1.5 to 13% and failed intubation has been
identified as one of the causes of death or permanent
brain damage related to anaesthesia.[2] Problems
in airway management can be predicted based on
previous anaesthesia records, the medical history
of the patients and a physical examination. Several
radiologic measurements were reported to be
associated with a difficult intubation. However,
simple clinical examination is a widely used method
to predict difficult intubation.
The incidence of difficult intubation in our study
was 8.3%. The validity of MMT to predict a difficult
intubation was low. The addition of TMP and SMT
to MMT for preoperative assessment improved the
validity of predicting difficult intubations.
In a study with a large sample size, researchers noted
that the combination of MMT and TMD were good
predictors of a difficult laryngoscopy in the Thai
population.[5] However, they had used TMD<6cm as
a parameter instead of<6.5cm used in the current
study. In another study, investigators assessed
Chinese females who were pregnant and those who
were not pregnant and found that the combination of
predictive variables could improve the validity.[6] A
study from the USA found that by using as many as
ten measurements, aggregate set of variables improved
predictability of a difficult intubation.[7] Iohom etal.
performed a study in Ireland and noted that the
validity of positive predictive value of MMT increased
from 27 to 100% after combining other predictors.[8]
In contrast, the combination of MMT and TMD was
not an adequate predictor of a difficult intubation in a
study by Koh etal.[9]
The validity parameters could be affected by the rate
of outcome variables prevalent in the population
under study.[10] It was 8.1% in our study. Langaron
etal. found it to be 6.1%.[4] The incidence ranged
between 1.5% and 8%.[11] The higher rate of difficult
intubation in our study with Indian population is
worth noting, as we had not specifically included
bariatric cases.[12] Perhaps, racial differences
resulting in different anatomical features of
oropharynx and larynx could be responsible for
variability of difficult intubation among different
studies.
Age and weight in our study was not different among
those who had a difficult intubation compared to those
who did not have a difficult intubation. Therefore, we
did not attempt to use them as predicting factors. Sheff
etal.[11] also found that body mass index(BMI) was
not a predictor of difficult intubation. Older age was a
predictor of difficult intubations in Turkey.[13]
The validity of the MMT and TMD varies widely. The
sensitivity ranged from 42 to 91% while specificity
ranged between 66% and 84%.[14] The TMD although
is a more valid measurement for predicting a difficult
intubation and it is influenced by height of patient.[15,16]
The lack of data related to height due to clerical error
in data management in our study was a limitation. We
could not calculate BMI and role of height in predicting
a difficult intubation.
Tripathi etal. used5cm TMD value whereas Khan
etal. used SMD value of 13cm in their respective
studies.[17,18] This was different from the measurement
of 6.5 cm for TMD and 12.5 cm for SMD used
in our study. Alack of standardized TMD and SMD

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Patel, etal.: Validity of MMT, TMD and SMD to predict difficult endotracheal intubation
values to categorize the patients has resulted in wide
variation of predictability for a difficult intubation.
A more appropriate determination of validity is to
conduct analysis using ROC and AOC parameters
instead of categorizing it as continuous variable.[19]
We therefore plotted ROC of TMD and SMD. This has
been reported in previous studies; however, they used
a ratio of height and thyromental distance to find the
validity of a continuous variable.[15,16,20]
We conducted MMT in a sitting position. Singhal
etal. proposed that the MMT shows higher grades if
the patient is assessed in the supine instead of sitting
position.[21] Intubation usually is performed in the
supine position and hence validity of MMT measured
in the sitting position was not helpful in accurately
predicting a difficult intubation.
Adherence to the principles of the difficult airway
management algorithm and widespread adoption of
a precise plan for management of airway difficulties
should result in reduction of respiratory catastrophes
and a decrease in anaesthesiarelated morbidity and
mortality.[22]
CONCLUSION
MMT had high specificity. The validity of combination
of MMT, SMD and TMD as compared to MMT alone
was very high in predicting difficult intubation in
adult patients. All the three parameters should be
ideally used in assessing airway in adult patients for
surgery under GA.
ACKNOWLEDGMENTS
We thank the administrators of Sal hospital for permission
to undertake this study. We thank Dr.Mukesh Vakil for his
guidance and encouragement.
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Source of Support: Nil, Conflict of Interest: None declared
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